=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134467038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KILLINGTON MEDICAL CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2013
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3902 KILLINGTON RD
-----------------------------------------------------
City | KILLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05751-9822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-422-6125
-----------------------------------------------------
Fax | 802-422-6798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 205
-----------------------------------------------------
City | KILLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05751-0205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-422-6125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. EDWARD OGORZALEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 802-747-1630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | L0038157
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------